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Contents
Page
Section 1.
Summary
Section 2
Introduction
Section 3.
The Workshops
Section 4.
11
Section 5.
Conclusions
19
Appendix 1
Participants Responses
21
References
29
ii
Section 1 Summary
This report presents the findings and views of participants taking part in a series of
regional workshops (England) held during the period of November 2009 and February
2010. The workshops were facilitated and organised by the Royal Society for Public
Health (RSPH), with attending participants coming from a cross section of members of
the health promotion workforce. The project was originally commissioned by the
Department of Health (DH) as part of the wider Public Health Workforce Review to
provide insight into the role and related skills and competencies of specialists in health
promotion (and where possible the wider behaviour change workforce), alongside
recruitment and retention issues. It also was commissioned to provide an opportunity to
question the basis both academic and within the current NHS system, of the strength,
focus and use of the current specialist health promotion workforce.
Participants from the workshops have specifically identified the ongoing need for
specialists in health promotion defining the role as one that can work strategically,
bringing together and working within partnerships to tackle the determinants of health.
The capability to communicate with and engage stakeholders in actions to improve health
at the community and population level is seen as an important aspect of the specialists
role and something that emerged from a mix of experience, training and insight rather
than as a result of any one specific skill or competency.
Participants also highlight the significance of the function of health promotion specialists in
advocacy for health, enabling action for health and mediating for health. They are seen as
having a central and integral role to play as part of a flexible and multi-disciplinary
workforce in a rapidly changing health economy. Many participants believed that the
function and role should be protected and those fulfilling it given the status and freedom
to maximise its potential.
The term behaviour change workforce was not commonly understood or accepted by
participants indeed there was a strong antipathy towards its usage and a call for DH to
provide clarity of definition in terms of the roles, entry points and career pathways that
the behaviour change workforce embraces. The report therefore is more limited in this
area, none the less some useful participant feedback is included.
In terms of links to the educational and academic sectors, health promotion practice is
seen as being firmly underpinned by theory, this theory being tried and tested over
several decades. However there is a need to at least maintain and preferably increase
health promotion research funding and for academic institutions to continue to ensure
that the courses on offer are reflective of needs on the one hand and are encouraging the
development of new knowledge and practice within the sector. For this reason alone,
partnerships between the health and education sectors and other stakeholders are
important and need to be fostered.
Practitioners need for life-long health education training, must be integral to new DH
workforce development programmes and in this context a funded and co-ordinated
public health workforce development strategy is fundamental to ensuring a competent
workforce. This workforce needs to be culturally diverse and strengthened with cultural
competence. We recommend that active consideration should be given as to how best
to guard the reservoir of knowledge held by health promotion specialists. Ways in which
this might be done include the development of a clear career pathway, a raised profile for
the role, and a move, so far as is possible, towards embedded, long-term roles rather
than short, project specific employment contracts.
Workforce development is now a core element of many organisations planning and
improvement processes. It means developing the people in an organisation to improve
the way that services and activities are delivered. Done well, the outcome of workforce
development is a motivated, skilled, diverse and outward looking workforce capable of
delivery high quality services. Workforce development may also include the work an
organisation does to increase the recruitment and retention of high quality people. One
of the fundamental prerequisites for workforce development is gaining an understanding
of the development needs of the people who work in it.
Section 2
Introduction
Despite being 24 years in existence the principles and suggested practice of the Ottawa
Charter remains relevant and current. WHO has taken forward the concept and a series
of Global Conferences have addressed key elements of the Ottawa Charter Adelaide
(1988) Recommendations on Healthy Public Policy; Sundsvall (1991) Statement on
Supportive Environments for Health; Jakarta (1997) Leading Health Promotion into the
21st Century; Mexico (2000) The Promotion of Health: From Ideas to Action; Bangkok
(2005) The Bangkok Charter for Health Promotion in a Globalised World.
Influencing public policy, driving forward the creation of supportive environments,
reorienting health services (from disease towards health), strengthening community
action and developing personal skills for health among the population are issues that have
been addressed by many stakeholders. The real added value / beneficial outcome is
achieved when the approach is championed, coordinated across sectors and settings and
has stakeholder engagement.
Health promotion has thus evolved to recognise the influence of broader social policies,
environmental and specific workplace factors, not just individual factors in efforts to
promote health. The key to health promotion is the commitment to evidence based
decision making, collaboration with stakeholders, and especially, commitment to common
values and assumptions about the importance of the upstream factors impacting health
(Labonte and Spiegel, 2003). The traditional approach to health promotion with its focus
on individual lifestyles has been replaced by a methodology that is system based and
multi- level in nature.
In developing these activities leadership and the ability to work across boundaries, plus
the ability to see the pattern in the jigsaw before the pieces are assembled are essential.
Traditionally this leadership role has been fulfilled by health service staff with a specialism
in health promotion, and in many instances this continues to be the case, even though job
titles and roles may have changed as has the organisational and work environment in
which those with responsibility for improving health operate.
In order to contribute to workforce standards and competence for future public health
delivery the DH commissioned the RSPH to organise and hold meetings of the health
promotion workforce on behalf of the DH, on five key themes:
1. Should there be defined specialists in health promotion?
2. What features of the health promotion workforces competencies are unique?
3. Does health promotion have a strong academic underpinning?
4. What issues are there in recruitment, retention and capacity in the current health
promotion workforce?
5. What are the core skills of health promotion?
The finding of the workshops will be summarised, and a synthesis provided of the main
concerns, insights and implications for each of these thematic areas.
This project aims to:
provide insight into the current sets of skills held by health promotion and
behaviour change workforces;
provide an opportunity for consideration of recruitment and retention issues for
these workforces;
create an opportunity to question the basis both academic and within the
current NHS system, of the strength focus and use of the current workforces. It
is important, timely and undertaken in the context of the development of the
workforce.
Section 3:
The Workshops
Process
Workshops were held at four locations (London x2 workshops, Bournemouth,
Birmingham and Leeds) during January and February 2010. Locations were chosen on the
basis of convenience for those attending and to ensure reasonable geographic coverage
across England.
Invitations to attend were sent out during December 2009 and January 2010 with the aim
being to have 12 15 participants at each workshop.
The actual number of attendees was as follows:
The workshops were of 3.5 hours in duration and were shaped around a series of
questions which were used to trigger and facilitate discussion. Participants worked in
small groups and in responding to the questions were asked to reflect on their
experience and consider current and future issues rather than historical ones.
Information Collection
Each group discussed the questions, made a record of their responses on flip charts and
then fed these back to the group as a whole, which in turn led to further discussion and
debate.
The facilitator of the workshop made a written record of this discussion and the
comments were also recorded digitally.
Assessment of Participants Responses
All the written and aural material was reviewed and the responses to each of the
questions assessed and the themes that emerged from the responses identified.
In setting out the themes that emerged we have grouped them under each of the
questions. Several themes apply across several questions and these are referred to in the
discussion. It is important to note that these are our groupings of the reactions of the
participants to the questions other people might group the responses in an alternative
way.
In discussing these issues we give more weight to the common themes, while
acknowledging that very significant and equally valid issues were sometimes only identified
in one workshop.
The Questions
The following table sets out the questions used in each of the workshops. The significant
difference between the questions used in workshops 1, 4 and 5 with those used in
workshops 2 and 3 is due to a request from the client that the focus be oriented to
include the behaviour change workforce. In practice however the use of the term created
difficulty in the minds of the participants, and despite steps to clarify the meaning of the
term for the third workshop the problems remained in place. This point is explored
further in the section dealing with the themes that emerged.
For workshops 4 and 5 two questions in workshop 1 (Qs 2 and 5) were combined.
Workshop Questions
London
25th January
Bournemouth
3rd February
Birmingham
8th February
London
February
Q1.
Q2.
11th
Leeds
February
22nd
London
25th January
Bournemouth
3rd February
Birmingham
8th February
London
February
11th
Leeds
February
22nd
Q3.
Is there a unique
academic knowledge
base underpinning
practice in behaviour
change, including health
promotion?
Is there a unique
academic knowledge
base underpinning
practice in behaviour
change, including health
promotion?
Q4.
London
25th January
Q5.
Bournemouth
3rd February
Birmingham
8th February
London
11th February
Leeds
22nd February
10
Section 4:
During the workshop process several factors came to light. First and foremost among
these was the willingness of the participants to contribute to the discussion and
debate. The debate was lively, challenging and involved reflection and considered
opinion as well as the expression of strongly held views.
The use of the term behaviour change workforce created some difficulty as it is a
term with which only one or two of the total number of participants were familiar. A
review of the literature using the search term behaviour change workforce was
undertaken using Medline, Cinahl, Psychlit etc.
This revealed one use of the term in the UK and Europe, and that was in a document
produced by South Yorkshire and Humber Strategic Health Authority, where it is
stated that, Several South Yorkshire PCTs identified the enormous task ahead of
them in skilling their wider pubic health workforce in the basic principles of behaviour
change, and that in response to this, A behaviour change workforce competence
framework including brief interventions, due for completion by summer 2009, has
been commissioned from Sheffield Hallam University. The document does not define
the behaviour change workforce but it would seem to indicate that the potential role
of the wider public health workforce in promoting positive behaviour change has been
recognised and addressed. The issue which remains unaddressed is that of the
positioning and remit of health promotion specialists.
Between the first London and the Bournemouth workshop a working definition of
behaviour change workforce was developed by the RSPH team. This takes a broad
view of the behaviour change workforce and is expressed thus, The Behaviour Change
Workforce is an all embracing term referring to anyone who is professionally involved in
promoting or assisting health related behaviour change either at the population, community
or individual level.
Despite this, the participants in workshops 2 and 3 found the expression behaviour
change workforces, including health promotion difficult to relate to their experience,
where behaviour change is part, but by no means all of the role of a health promotion
specialist. This was seen to be a diminution of health promotion and was a major
cause of contention and potential concern.
The final observation that warrants comment in this manner is the clearly expressed
concern about the status, positioning and functioning of health promotion within
public health as a whole.
11
Discussion
1.
majority of the population that is well, or that has well managed health
conditions. From a societal perspective, keeping these groups well and
economically active is an essential component of actions that need to be taken
in order to maintain the UKs competitiveness. The challenge facing many
commissioners, and indeed Government itself is that health is often measured
by the public in terms of the number of medical interventions that are
completed for those who are unwell, rather than on what is being done to
prevent those who are well becoming ill. At times of economic constraint, this
emphasis on societal action to promote health is in sharp contrast to the
desire held by many to treat in as speedy and comprehensive a way as possible
illness and disease.
It was noted that the census of health promotion specialists carried out in
2006 as part of the Shaping the Future initiative showed a 50% reduction in
the number of health promotion specialists. This reduction had possibly
further increased since the census publication and reinvestment in the
specialist service is urgently needed to fulfil the well being agenda.
2.
3.
Capacity
In general, capacity was not felt to be such an issue, largely as a result of the
way in which health promotion was now delivered i.e. short term, setting or
topic specific projects for which people with relevant experience could be
found.
However in the context of the more strategic, proactive roles capacity was
felt to be an issue in terms of relevant experience and expertise. Defined gaps
14
in the skill level of some of those in higher band roles were identified and it
was perceived as being difficult to gain experience in health promotion in
these types of role and this impacted on a whole system approach to capacity
building.
Potential over skilling of lower bands within the NHS Skills Framework and
the Public Health Skills and Careers Framework were also highlighted as a
potential capacity issue. Conversely, it was felt that high pressure is placed on
lower bands and is created by the expectation that staff in these grades can
do anything, even when what they are being asked to do is outside their level
of competency and/or experience.
4.
15
16
5.
18
Section 5
Conclusions
It is worth remembering that in fulfilling its role the health promotion workforce
engages the public as a resource, not as a target group, and it is this giving of
ownership and enabling of action that highlights the potential of this workforce to
make a sustained contributing to the improvement of health in England. It is in the
development of upstream, disease prevention initiatives that population health will be
maintained and improved, but in times of economic restraint the expectation of many
is that front line treatment services should be maintained above all others often at
the costs of disease prevention and health promotion activities.
The definition of essential public health services (as opposed to specific public health
system professions) is important. In considering how best to contribute to workforce
standards and competence for future public health delivery the following points
should be borne in mind:
The need for specialists in health promotion continues these are individuals
who can work strategically, bringing together and working within partnerships
to tackle the determinants of health. This group is able to communicate with
and engage stakeholders in actions to improve health at the community and
population levels and brings to the process a wide range of skills and
competencies it is the mix of these rather than any one specific skill or
competency that is key. Those working in 1:1 situations with patients / clients
and dealing with important disease related risks are equally important, but are
fundamentally different in nature.
The significance of the function of health promotion specialists in advocacy for
health, enabling action for health and mediating for health cannot and should
not be underestimated. They have a central and integral role to play as part of
a flexible and multi-disciplinary workforce in this rapidly changing environment.
This function and role should be protected and those fulfilling it given the
status and freedom to maximise its potential.
19
20
Appendix 1
1.
a.
The overwhelming answer from all workshops and all groups was yes.
b.
c.
21
1a.
2.
Unique competencies:
Understanding of health, the ecology of health and the salutogenic
approach to health
Upstream thinking on health and wellbeing and wider determinants of
health
The knowledge and skills to work in a strategic way
Communication (using a range of tools and approaches)
The ability to work with organisations and groups rather than on
them in a way that is inclusive and collaborative in nature and results in
capacity building and community engagement and empowerment
22
23
2a.
3.
24
c. Several problems with the current position were identified, but a solution
was not identified for all:
A lack of benchmarking of health promotion as a discipline
That health promotion is an eclectic discipline drawing on the
knowledge and skills from other disciplines
That knowledge and skills have stagnated
That some practice is not well underpinned by theory
3a.
25
4.
4a.
26
The roles are not always embedded again funding is short term, and
so people have to move to other positions as they approach the end of
their project / and fixed term contract
Career progression for staff on lower salary bands is limited, those
with or who gain additional qualifications move into new roles as soon
as they can
Capacity
Potential over skilling of lower bands
5.
5a.
27
References
R. Labonte and J. Spiegel, "Setting global health research priorities", British Medical
Journal, 326, 5 April 2003: 722-723.
Third International Conference on Health Promotion, Sundsvall, Sweden, 9-15 June
1991. Sundsvall Statement on Supportive Environments for Health
http://www.who.int/healthpromotion/conferences/previous/sundsvall/en/index.html
Second International Conference on Health Promotion, Adelaide, South Australia, 5-9
April 1988. Adelaide Recommendations on Healthy Public Policy
http://www.who.int/healthpromotion/conferences/previous/adelaide/en/index.html
Third International Conference on Health Promotion, Sundsvall, Sweden,
9-15 June 1991. Sundsvall Statement on Supportive Environments for Health
(WHO/HPR/HEP/95.3) http://www.who.int/hpr/NPH/docs/sundsvall_statement.pdf
Jakarta Declaration on Leading Health Promotion into the 21st Century
http://www.who.int/hpr/NPH/docs/jakarta_declaration_en.pdf
The Fifth Global Conference on Health Promotion Health Promotion: Bridging the
Equity Gap . Conference Report. 5-9th June 2000, Mexico City
http://www.who.int/hpr/NPH/docs/mxconf_report_en.pdf
The Bangkok Charter for Health Promotion in a Globalized World (11 August 2005)
http://www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/
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